Inappropriate Psychotropic Agents for the Elderly
by Rajender R. Aparasu, Ph.D., Jane R. Mort, Pharm.D., and Anuradha Aparasu,
M.D.
| Geriatric Times |
 |
March/April 2001 |
|
Vol. II |
|
Issue 2 |
Pharmacotherapy plays an important role in the management of psychiatric
illnesses in the elderly, but it can be a challenge. Age-related changes
unfavorably affect many psychotropic drugs by altering drug pharmacokinetics
and pharmacodynamics (Naranjo et al., 1995). These alterations sometimes lead
to physical and nervous system side effects, such as reduced mental
functioning, sleep disturbances and falls, which may result in hip fractures
(Beers and Ouslander, 1989; Ray et al., 1987). Furthermore, polypharmacy and
comorbidity complicate psychopharmacotherapy.
Inappropriate Medications for the Elderly
Beers and colleagues (1991) developed explicit criteria to identify
inappropriate medications, including psychotropics, for the frail elderly.
These criteria, developed through literature and consensus methodology, were
based on the potential risks and benefits of medications. The consensus process
involved a two-round written survey of 13 experts in geriatric medicine and
geriatric pharmacology. The survey identified medications that should be
generally avoided and doses and durations of drugs that should not be exceeded.
The list of 20 medications from these criteria, which excluded dose- and
duration-dependent inappropriate medications and antihypertensives, was the
focus of several studies including a report by the U.S. Government Accounting
Office (GAO) (Aparasu and Mort, 2000; GAO, 1995).
Studies using the Beers criteria or portions of the criteria indicated that
14% to 40.3% of elderly patients in various settings received an inappropriate
medication (Aparasu and Mort, 2000). The majority of the elderly patients using
inappropriate medications were only using one inappropriate agent. Among
inappropriate medications, patients most often used long-acting
benzodiazepines, dipyridamole (Aggrenox), propoxyphene (Darvon) and
amitriptyline (Elavil, Endep).
In 1997, Beers revised the list of inappropriate medications to apply the
criteria to all people over the age of 65. Using a consensus panel of six
nationally recognized experts in geriatric care and pharmacology, he also
redefined the list of inappropriate medications. It included medications that
should be generally avoided (disease-independent) and others that should be
avoided because of patients' pre-existing disease or condition
(disease-dependent). Many of these medications were deemed inappropriate due to
their relative ineffectiveness or adverse outcomes and the existence of safer
or more effective alternatives. The psychotropic drugs grouped as the
disease-independent and disease-dependent inappropriate medications along with
suggested alternatives are listed in Table 1
and Table 2, respectively. (Table 1 offers
paroxetine as an alternative to antidepressants due to its decreased
anticholinergic effects; however, it does have some mild anticholinergic
activity which may be problematic in susceptible individuals-Ed.)
Inappropriate Psychotropic Agents for the Elderly
In studies based on Beers' criteria, psychotropic agents comprised a large
portion of the inappropriate medication use (Mort and Aparasu, 2000). One in
four to one in six psychotropic prescriptions for the elderly in ambulatory
settings involved inappropriate medications (Aparasu et al., 1998; Mort and
Aparasu, 2000). Among psychotropic agents, long-acting benzodiazepines and
amitriptyline comprised the majority of this inappropriate prescribing;
therefore, great emphasis should be placed on the appropriate use of
psychotropic agents, specifically antidepressants and antianxiety agents.
Amitriptyline and doxepin (Sinequan) accounted for the majority of the
inappropriate antidepressant prescribing (Mort and Aparasu, 2000). These agents
are considered inappropriate due to their high anticholinergic effects and
sedative quality (Beers, 1997). This can lead to problems ranging from urinary
retention to delirium (Pollock, 1999; Salzman, 1999; Zisook, 1998). Given the
vast number of alternatives available to treat depression, such agents can be
easily avoided. A preferred approach to depression in theelderly would be a
selective serotonin reuptake inhibitor (SSRI), initiated in the elderly at
one-third to one-half of the dosage used in the younger population (Salzman,
1999). These agents have better tolerated side-effect profiles, do not require
as much dosage adjustment and appear to be as efficacious as tricylic
antidepressants in most types of depression (Salzman, 1999; Zisook and Downs,
1998).
In the management of anxiety, long-acting benzodiazepines are considered
inappropriate because of their prolonged elimination and subsequent elevation
in blood levels that may increase sedation and ataxia and lead to increased
incidence of hip fractures (Beers, 1997; Small, 1997). A recent study suggests
that any of the benzodiazepines may be associated with hip fracture (Burke et
al., 1998). Alternatives include the short-acting benzodiazepines and buspirone
(BuSpar). The short-acting benzodiazepines' elimination is typically less
affected by the aging process (especially lorazepam [Ativan] and oxazepam
[Serax], which are metabolized by the glucuronidation pathway). This makes
dosage adjustment easier and side effects less likely (Burke et al., 1998).
Buspirone, on the other hand, does not cause the sedation or psychomotor
slowing that benzodiazepines do (Burke et al., 1998; Schneider, 1996).
Buspirone's onset of action may be delayed up to three to four weeks, though,
and the absence of euphoria may be unacceptable to some patients previously
receiving a benzodiazepine (Burke et al., 1998). Despite these limitations, the
improved side-effect profile makes buspirone a good alternative.
Flurazepam (Dalmane), also considered to be an inappropriate agent, is a
long-acting benzodiazepine used to treat insomnia (Beers, 1997). While
pharmacological management of insomnia is only recommended for a short duration
(Hauri, 1998), there are agents preferred due to the same factors previously
described for anti-anxiety agents. Short-acting agents also produce less
daytime sedation because their levels in the blood fall quickly, thereby
enhancing the patient's task performance the following day (Folks and Burke,
1998). Non-benzodiazepine agents such as zolpidem (Ambien) and zaleplon
(Sonata)have very short half-lives and have been purported to have fewer side
effects(Hauri, 1998; Folks and Burke 1998). Antidepressants such as trazodone
(Desyrel) may also be used, but care must be taken because of the high
potential for orthostatic hypotension (Zisook and Downs, 1998).
Selection of agents to treat mental health disorders for an elderly patient
is a complex task. Pharmacokinetic and pharmacodynamic changes with aging
greatly influence this process (Burke et al., 1998; Small, 1997; Zisook and
Downs, 1998). The increase in body fat, decrease in liver function and
diminished renal activity that often accompany aging make blood levels higher
and retention of medications within the body greater (Burke et al., 1998;
Small, 1997; Zisook and Downs, 1998). This is not true for all psychotropic
agents, but, for those affected, the outcome can have dramatic results.
Therefore, once an agent is selected, careful patient evaluation and monitoring
is required and initiation of psychopharmacotherapy should follow the old adage
of "start low and go slow."
Opportunities for Improved Geriatric Care
According to the GAO report (1995), several behavioral factors contribute to
inappropriate medication use in the elderly population. Some of these include:
physician practices based on outdated prescribing information; pharmacists not
conducting drug utilization reviews; and lack of communication between
providers and patients. Efforts are needed to improve prescribing practices and
quality of care for the elderly. Psychiatrists, who have more expertise in
psychopharmacotherapy, have the lowest inappropriate psychotropic prescription
use (Aparasu et al., 1998). Continuing education programscan be effective in
informing physicians about recent geriatric psychopharmaco-therapy issues.
Also, active communication between physicians, pharmacists and patients can be
useful in ensuring quality drug therapy for the elderly.
Other factors associated with inappropriate prescribing may also help
practitioners to efficiently focus their efforts. It has been found that
increased patient age is associated with inappropriate prescribing of
psychotropic agents. In fact, the odds of prescribing an inappropriate
psychotropic medication were found to increase by 2% for each additional year
of an elderly patient's age (Mort and Aparasu, 2000). These results should
encourage health care providers to be more pragmatic and careful when selecting
therapy for their elderly patients. On the other hand, Medicaid status was
associated with less inappropriate psychotropic medication prescribing (Mort
and Aparasu, 2000). Many Medicaid programs have prescription plans that involve
drug utilization reviews. This type of monitoring of medications may account
for the improved prescribing practices and would support the use of medication
review in other programs.
The inappropriate prescribing of psychotropic medications also increased by
16% for each additional medication prescribed (Aparasu et al., 1998). With
polypharmacy already a major concern in health care, this information further
emphasizes the importance of carefully selecting agents and avoiding
unnecessarymedications. Not surprisingly, use of antidepressants and
antianxiety agents also increased the likelihood of prescribing inappropriate
medications; hence, additional caution should be employed when agents from
these classes are prescribed (Aparasu et al., 1998).
Healthy People 2010, a national initiative to improve the health of all
Americans, is planning to ensure regular review of medications used by older
patients. To achieve this objective, it intends to increase the proportion of
primary care providers, pharmacists and other health care professionals who
routinely review medications of their patients aged 65 years and older.
Prospective and retrospective drug utilization programs conducted by
pharmacists can improve geriatric care by monitoring and preventing
inappropriate medication use. Physicians are also encouraged to incorporate
medication reviews as part of routine office-based practice (American Medical
Association, 1998). With growing scientific information on geriatric
drug-related issues, there is a greater need for better communication among
providers, researchers and health care institutions to prevent inappropriate
medication use and improve geriatric care.
Dr. Rajender Aparasu is associate professor of
pharmaceutical sciences in the College of Pharmacy at South Dakota State
University. He has extensive research experience in the area of medication use
in the elderly and drug-related morbidity.
Dr. Mort is professor of clinical pharmacy in the College of
Pharmacy at South Dakota State University and practices on a geriatric
assessment team at Rapid City Regional Hospital in South Dakota.
Dr. Anuradha Aparasu is a medical resident in the internal
medicine program at the University of South Dakota School of
Medicine.
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